eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Epistaxis

Author: William Gluckman, DO, MBA, FACEP, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital; Attending Emergency Physician, St Joseph's Regional Medical Center; President and CEO, FastER Urgent Care
Coauthor(s): Robert Barricella, DO, FAAP, FACEP, Director of Pediatric Emergency Department and Emergency Fellowship, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey; Huma Quraishi, MD, Division Director, Assistant Professor, Department of Pediatrics, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey; Sangeeta Lamba, MD, Resident Physician, Section of Emergency Medicine, University Hospital, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Oct 27, 2008

Introduction

Background

Epistaxis, or nosebleed, is a common pediatric complaint. Most incidents are rarely life threatening but cause significant parental concern.¹ Most nosebleeds are benign, self-limiting, and spontaneous but may also be recurrent. Many uncommon causes are also noted.

Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, based on where the bleeding originates.

Pathophysiology

Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. More than 90% of bleeds occur anteriorly and arise from the Little area, where the Kiesselbach plexus forms on the septum.² The Kiesselbach plexus is where vessels from both the internal carotid artery (anterior and posterior ethmoid arteries) and the external carotid (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a constant ooze, rather than the profuse pumping of blood observed from an arterial origin.

Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin. A posterior source presents a greater risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.

Age

Epistaxis usually occurs in children aged 2-10 years. Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients.

Clinical

History

• Most nosebleeds are reported as spontaneous events and are frequently related to nose picking or other trauma; therefore, investigate the various possibilities.
• Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may be less and accompanied by foul or purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a foreign body.
  • Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into their nostrils.
  • Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries.
  • Removal is a priority; removing the batteries within 4 hours of insertion is best.
• Obtain a history of aspirin or warfarin use. Include investigation of suspicion of accidental ingestion (consider accidental ingestion of rat poison in toddlers).
• Obtain any family history of bleeding disorders or leukemia.
• A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive family history of bleeding, and anemia.
  • Although unusual, children with bleeding disorders (eg, von Willebrand disease) can occasionally have normal coagulation profiles.
  • More than one sample may be required to notice the abnormality due to biologic variability throughout the day.
• Obtain a history of whether the bleed is unilateral or bilateral and if it occurs following exercise. Also, determine if the onset was during sleep or associated with a migraine.
• Determine through history if hematemesis or melena occurred because posterior bleeding in particular may present in this fashion.

Physical

• Nasal examination
  • Use of a large-sized, otologic, handheld speculum can be helpful (see Media file 1).
  • Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery.
  • Anterior bleeds from the nasal septum are most common, and the site can frequently be identified if bleeding is active.
  • Carefully remove by suction any large amount of clot.
• Pharynx examination
  • Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed.
  • After placement of an anterior pack, reassess this area and, if bleeding is noted in the pharynx with an anterior pack in place, strongly consider a posterior bleed (see Media files 3-4).
• Skin: Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.
• Vital signs
  • High blood pressure (HBP) rarely, if ever, causes epistaxis on its own; however, HBP may impede clotting. Check blood pressure and complete a workup if HBP is present.
  • Persistent tachycardia must be recognized as an early indicator of significant blood loss requiring intravenous fluid and, potentially, transfusion.

Causes

• The primary cause of epistaxis in children is minor trauma, such as nose picking (frequently in the setting of dry nasal membranes).
• Other common causes of nosebleeds include direct trauma with or without nasal or facial fractures, foreign body, rhinitis, and exposure to warm and dry air causing dry membranes (rhinitis sicca). Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and chronic use of nasal steroids for treatment of allergic rhinitis are also frequently involved.
• Some less common causes include leukemia, Osler-Weber-Rendu syndrome, nasal tumors, and coagulopathies, both intrinsic (eg, hemophilia, Von Willebrand disease) and acquired (eg, accidental warfarin ingestion).
• Excessive coughing causing nasal venous hypertension may be observed in pertussis or cystic fibrosis.
• Arterial hypertension rarely causes epistaxis.
• Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease.³ The Kiesselbach plexus, which is part of the trigeminovascular system, has been implicated in the pathogenesis of migraine.⁴
• Young infants with gastroesophageal reflux into the nose may have epistaxis secondary to inflammation.
• Etiologies such as liver disease, which can lead to clotting factor deficiencies (II, VII, IX, X); Osler-Weber-Rendu syndrome, which causes capillary fragility; and nasal foreign bodies that cause local trauma can be responsible for rare cases of epistaxis.
• Intranasal rhabdomyosarcoma, although rare, often begins in the nasal, orbital, or sinus area in children.
• Juvenile nasal angiofibroma in adolescent males may cause severe nasal bleeding as the initial symptom.

• Search for CME/CE on This Topic »

• Nasal Pack, Anterior Epistaxis (Clinical Procedures)
• Nasal Pack, Posterior Epistaxis (Clinical Procedures)
• Epistaxis (Otolaryngology and Facial Plastic Surgery)
• Epistaxis (Emergency Medicine)

• Ear, Nose, and Throat Center
• Nosebleeds Symptoms
• Nosebleeds Treatment
• Nosebleeds Overview
• Nosebleeds Causes

• Once-Daily Azelastine Nasal Spray Approved for Seasonal Allergies
• Nasal Spray May Reduce Viral Shedding and Rhinovirus Transmission
• Bleeding Disorders May Cause Menorrhagia and Postpartum Hemorrhage

• A Reconsideration of Acute Beryllium Disease
• Nasopharyngeal Carcinoma: The Role of the Epstein-Barr Virus
• Effect of Atorvastatin on the Pharmacokinetics and Pharmacodynamics of Prasugrel and Clopidogrel in Healthy Subjects